GEN STORES

TITLE : REQUEST FOR REPAIR / REPLACEMENT - TRANSPORTATION SERVICES

To

From Dept. INSTRUMENTATION

Section ESF
Date :
Material - Returnable / Non Returnable ?
Cost Centre : M11401

GENERAL STORES - (Manager - SMS)

Kindly arrange to send the folllowing Material for :

A Repair

B Replacement

C Testing / Calibration

04.06.2015
Returnable

D Other Services

to the manufacturer / vendor / service centre / Laboratory etc at the following address indicated below, as per the agreed terms / conditions indicated below :
A Name & Address (Where the Material is to be sent)

Contact Peson :
Phone Nos. - Works / Office

Kevin Technologies Pvt. Ltd.

B-302, Safal Pegasus,
Nr. Prahladnagar Garden,
Anandnagar,
Ahmedabad - 51
B Details of Item/s to be sent :

Fax No. - Works / Office

E mail address :

M/s. KEVIN TECHNOLOGIES

PVT.LTD.
PH - 079-2687 2555
FAX - 079-26878930
Info-ktpl@kevin.in

Any other information

MOBILE: 92277 24143

Contractual Conditions :
PO No. :
RFQ No.
PR No.

3200088368

Letter Ref.

Note : In case of more items, please attach additional sheet in the prescribed format

Sr.

Item/s Descrip.with Equip. Details

Make / Supplier

1
2
3

101399300018 - PROFACE HMI

2500 REPAIR

PROFACE

Year of Mfg./ Supply

Ref. PO No.

Qty. Approx. Wt (Kg) Esti.Depreciated Value

Remarks

4
5

Total No. of Items, Wt. In Kg & Depreciated Value (Rs. Approx.)

C Verification / Information Checklist : (To be filled By concerned dept.)
Sr
1
2
3
4
5
6

Information / Attribute

User Input

Freight Charges - While sending - By TCL / Vendor :

Freight Charges - While returning - By TCL / Vendor :
Vendor's Ref. Letter, if any.
- (Ref. No. )

If under Annual contract / Warranty ? Pl specify

Mode of Transport - Despatch / Return.
Transit Insurance if required - TCL / Vendor / NA
Information furnished by (Dept. )

Name
Sign
Date :

SIBABRATA CHOUDHURY
Phone No. :
6/4/2015

9227029320

TCL
Vendor
NA
NA
Despatch
NA

Approved by HOD

Sr.
1
Sr.
1
2

Information / Attribute

Stores Input

Form No.402 Requirement, if applicable

Or any other Road Permit Requirement?
Information / Attribute

Duty &Tax. Input

Whether Modvat/CENVAT availed - (Yes / No ) ?

Form No.4(5)(a) Required, if applicable

Reviewed by Purchase dept.

Duty &Taxation Dept.

General Stores : Processing Data :

Name
Sign

Name
Sign

Received

Sign
Date :

Date

Date

DA No. :

Sign

Despatched

Sign

QSF-090-07-02

Rev. No. : 1

Rev. Date : 24-05-04

Repairing Testing /
Callibration /
Inspection
/ Analysis
/ Sample

Only
Transport